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Process Recording with Heartland Patient

Process Recording with Heartland Patient

Victoria C. Kronauer

University of Akron
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Process Recording with Heartland Patient

Introduction

The patent that was interviewed was more that comfortable in giving the information that was

needed to complete the assignment. The patient was easy to talk to and answered the questions

without hesitation. The patient was interviewed before the chart was viewed which helped because the

interaction was non bias and it was better to learn to recognize the patients problems and try and

compare it with the diagnosis.

A mental status exam was completed while talking to the patient. The patient was A&O x 2. The

patient was able to perform successful ADLs. The patient seemed slightly dazed and to some extent slow

to respond. The patient’s mood was clam, happy, sad and mad throughout the conversations. The affect

was congruent to the mood. The thought content was simple and sometimes excessive to the situation.

The patients thought content was concrete. The patents appearance was appropriate. Speech was

slow to respond and relaxed. Memory/concentration was irregular. The patient could not remember

some questions and could not comprehend some small things but was able to remember almost all the

patents names and the following week was able to remember Rachael’s name even though she called

me Rachael. The patient’s perceptions were rational.

GAF=45-50

Axis I: Schizophrenia (remission), Bipolar disorder

Axis II: Mild Mental Retardation

Axis III: obesity, Hyperlipidemia, Hypothyroidism, Osteoarthritis, Chronic Back pain, GERD, Seizure

Disorder (as child)

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Process Recording with Heartland Patient

Axis IV: Support Stressor, Housing Stressor, Legal/ Crime Stressor, Psychosos Stressor

The setting was in the unit in a small room used for semi private talks. The walls were white with

a few pictures and two small tables with a couple standard chairs. The door was left open and there

were big windows to see in to the hallway. The floor was hard tile and the room was located in the front

of the unit so there was a moderate level of noise. There were minimal people coming in and out.

All the phases were included in the conversation that was shared. The there were two halves of

a conversations in total and the first one will be discussed since it had a termination phase where the

continuation of the conversation after lunch was cut short due to a staff member. My orientation phase

was commenced when I introduced myself and asked if I could sit down. I told the patient who I was

and what I was doing at the hospital. This allows the patient to know I am honest and polite. This was

intended to build a relationship so the patient would feel comfortable. The working phase started when

the patient was going through a problem and I was there to offer a therapeutic conversation where at

the end she felt better. This phase cannot happen without first having a successful orientation phase.

The Termination phase happened when I needed to go to lunch. I told her why I had to go and made

sure she knew it was not because she was unimportant. I also told her I would be back and kept my

word, which is also important to build trust.

The objective for the therapy was at first to get a patient to have a conversation with me and

work on their personal interaction skills. That goal was met changed because there was an episode to

deal with and the goal was to level the client out and try to get the patient to think rationally.

Consequently I think my therapeutic approach improved but the main focus was on the patient.

My goal was simply to get a patient to open up to me and be able to feel comfortable enough to

share their feelings. I wanted to come off as caring and someone that would help.
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Process Recording with Heartland Patient

Nurse Data Client Data Self-Awareness Evaluation

* Introductions and small talk were left out

1. *Broad opening
How are you feeling I feel good. I am happy I was still anxious *It was effective
today? because I get to go to because it was one of because I was able to
the windmill store. the first patients I get the patient to tell
(tense, trying to make talked to at Heartland. me her feelings.
eye contact) (eating, not too It might have made me *How would you say
interested) less approachable. your day is going so far?

2.
What about the I got a coupon to get At the time I was aware *Exploring
windmill store makes earrings. Do you want that this response and * looking back it was
you happy? to see my ring, and my question were effective because it
bracelet, and my superficial so I wanted built repor.
(smiling) necklace, and my nail to go deeper, but now I *Can you explain to me
polish? They are all very realize that a couple what the windmill store
pretty. superficial is and why you get to
Yes they are. You must answers/questions go?
like jewelry a lot. (looks more intrigued) makes the client more
relaxed with me.
Yes it’s pretty.

*Pt. was eating lunch, then she got up to throw away the tray. She gave away her juice to another
patient, who has diabetes. She was told to throw her juice away 5 min ago by a staff member. That staff
member, consequently yelled at the patient with more than a firm/ very rude tone. It seemed
ridiculous to be that loud and make the patient feel that bad since the patient was not being malicious.
3. I was feeling very *Reflecting
Do you understand why I didn’t mean to, and uneasy because I *Even though that is
that lady was yelling at now they are going to thought the staff was not what I wanted to
you? write it down. mean to the patent and say, that is the way it is
I wanted to take the on the unit and I have
(crying, helpless) patent’s side. I knew to try and get the
(Stern[because of the that would not be patient to comprehend
staff not the patient]) beneficial to the patient and be understanding.
so I looked at it from It was smi-effective.
the staff’s point of view. *Why did you think it
was alright to give the
juice to your
roommate?
4. *Making
I know you didn’t mean Now I can’t go to the I felt like I needed to tell Observations/Informing
to, but you know you store and get my her It was not a *I think it was effective
have to follow the rules. earrings. reflection on her being because I made it clear
She was just trying to bad but that she did not she was in the wrong
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Process Recording with Heartland Patient

protect the patient. It listen. I didn’t want her but still softened it so
doesn’t make you a bad (sad, no eye contact) to feel as if she was she was willing to listen.
person. awful. It made me sad *Even though you
(comforting) to see her cry. might not have been
trying to be mean you
need to follow rules.
*exploring
I was starting to feel a *I think that it was
5. little less tense because effective but could have
How do you feel about It makes me sad, mad, the staff member was been said in another
that? and angry. not in ear shot. way because I had
already said it like that
(tight lips, narrow eyes) in the first interaction.
(sat a little closer) *Do you think that you
should still be allowed
to go?
6. *Focusing
Are those feelings to Yes. You know, I almost I was thinking that it I initially used that
blame for bringing you stabbed a police man. was very interesting question to remind the
here? And another time I was and I wanted to know patient that getting
so mad I pushed my more details in a weird mad and acting on it
mama down the stairs. I way because the people was not a good idea
love my mama. that I meet day to day because that is what
(tensing up) do not have a story like gets her in trouble. It
(wide eyes, informative) that. I was intrigued. was semi effective
because it also brought
up past bad moments.
*It is okay to get upset
but you need to
understand why you got
yelled at so you can
avoid that in the future.
Being angry does not
solve problems.
7. *Refocusing
I bet you have come a Yes I watch T.V. and talk Even though I wanted *It was effective
long way since then. Do to people like you. You to talk more about her because now we got to
you have any way of make me feel better. crimes I thought it was talking about
making yourself feel not going to be therapeutic ways to feel
better when you are beneficial to her to better.
mad? (smiling) bring up the past. *That must have been a
rough time in your life.
(reserved) What makes you
different as a person
now?
8. *Exploring
I am glad that talking My brother is in prison I think by this time I was *This was not effective
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Process Recording with Heartland Patient

makes you feel better. and I can’t see him and I getting a little bored because she was talking
Do other people in your get sad and angry and was hungry. So I about her brother in
life make you feel ‘cause I am here and he might have been prison which makes her
better? is there. showing less interest. sad to think about.
*I’m glad that talking
(smiling) (frowning) makes you feel better.
Who comes and talks to
you?

9. *Reflecting/Exploring
Do you write him letters Yes, my favorite nurse I felt bad for her and *This was not very
when you are sad that wrote a nice one a bit her family and showed effective because I was
you can’t see him? ago. it by asking this just digging deeper into
question. a sad situation.
( cocking head) (staring into distance) *That must be very
hard for you. Who do
you get to see?
10. *Refocusing
Do you have any other My sister and my I was relieved to be *This was more
family that makes you favorite nurse. My moving away from that effective that the last
happy? sister is my guardian topic. two questions, but it
and comes to see my. was opening it up for
(calming, smiling) She is nice to talk to. another sad answer if
she did not have any
(smiling) family.
*Do you have any
friends here that make
you happy?

*Exit for lunch: we said our goodbyes and I told her I would be back on the unit after my lunch
break. She said she was happy that I was coming back.

*Enter after lunch: I founder her crying and she wanted to talk to me.

11. I was furious at the staff *General Lead

What happened that “Staff member” yelled member because when *I think this was
made you so sad? at me and told me I I left she was happy and effective because there
can’t go to the store when I came back she it had to be addressed.
(tense, intrigued) and now I’ll never get was crying. I was mad *What happened since
my earrings. Never. that the staff member we talked?
did not have any
(crying, narrow eyes, patients with her or
scrunched face) seem to care. I also felt
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Process Recording with Heartland Patient

helpless as a nursing
student because I
cannot confront the
staff.
12. I was very interested in *Exploring
How are you feeling? I want to hit something. her side of the story *This question was
I am so mad and angry. and may have come off effective however I had
as a little too already asked the same
(on edge) (hopeless, loss of enthusiastic. Also that question two other
control) answer made me times in our
realize I had to be conversation which
careful she did not get seems like it is too
violent but I did not feel much, also it is
like I was in danger. apparent how she feels.
*That is what happens
when you act out on
your anger. You need
to work on control.

13. I was surprised to hear *Informing/Focusing

You know if you hit Yeah I got to behave or that answer. It seemed *I think was not as
anything it will get you else she said they will like they dealt with her effective as intended
into more trouble and tie me up. problems by taking because it made her
you won’t get to go to things away or think of being tied up.
the store for a long (matter of factly) threatening her. I was *Being angry does not
time. If you are good mad because that is not mean you have to hit
you may get to go in a going to help her. something. It is okay to
couple days. The Although she needs to be angry but you need
windmill store is not know there are to deal with it better.
going anywhere. consequences, she also Why don’t we try and
(informative) needs to know they are do some breathing
there to help. exercises.
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Okay why don’t we
focus on things that
make you happy
instead?
(comforting smile)

The same staff member came into the room suddenly and very rudely told me that I needed to

stop talking to the patient because she made verbal threats to her roommate earlier. I said my

goodbyes and then the patent was sad again. Although I understand why the staff member thought I
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Process Recording with Heartland Patient

shouldn’t talk to her, I feel like someone should be talking to her because it makes her feel better to talk

it out. Constantly yelling does not seem to be a solution. I overheard the staff member taking to a

nurse and she said that she does not like students talking to her when she gets like that because the

patient gets madder because it keeps being brought up. That was not the case with our conversation.

We talked about her feelings and I focused on improving her mood which I thought was effective in the

first conversation and was about to be in the second.

The first half of the conversation was very beneficial to the client. The patient was very

disturbed because of the staff member that yelled. We were able to work through that issue for the

time being and the patient was able to focus on thing that made him/her happy. The second half was

on the same track but was stopped short. So, I was able to meet the goal for the patient because it was

therapeutic and was also able to meet the goal for myself because I was able to get a patient to open

and tell me his/her feelings. The strengths of the conversation were when the patient was expressing

feelings and when I noticed an improvement in mood. I can now look back and see the exact question I

used to extract a therapeutic response. This will be helpful in future interactions. My weakness in the

conversation was when I repeated questions and when I unintentionally brought up instances in her

past that made her sad. Also, I could have stopped to reflect and had more moments of silence instead

of asking question after question. I do not think this particular patient seemed to notice since the

patient was so eager to talk but, it is something to think about in the future.

The teaching/coaching really was not something that was fit into the discussion to a real extent.

There was not any teaching, almost at all, but, there was a little coaching. The patient and I talked

about what he/she usually does when things get difficult and she remembered to do those things. This

especially came into play when I reminded the patient that acting out on anger can only bring more

trouble for her. That seemed to help. “You know if you hit anything it will get you into more trouble
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Process Recording with Heartland Patient

and you won’t get to go to the store for a long time. If you are good you may get to go in a couple days.

The windmill store is not going anywhere” (Kronauer). I think more teaching needs to be done with the

patient to help him/ her channel her anger. I would proceed with teaching the patient too look at things

from a different perspective so he/she will not be quick to anger.

The pertinent assessment points that were evidenced by the data was her mild mental

retardation which was evidenced by her small vocabulary and simplistic answers. Also, her Bipolar

disorder was evident by her happiness followed by her ability to get angry within seconds to an

unprortional level. There are safely issues when dealing with this patient. She can become violent when

he/she gets upset. It is mostly just verbal threats but it can escalate. The patient made that apparent

when he/she told me that he/she wanted to hit something, and earlier said to the nurse that he/she

wanted to hit the roommate, who was not involved. The patient’s resources are that he/she is able to

communicate feelings and is able to talk things out. Also he/she has decent family support. The

constraints of the patient is that anger gets in the way of judgment and everything therapeutic he/she

has learned is forgotten. The patient also might scare people away unintentionally so the patient loses

support. The relationship patterns that have been lost along the way is with his/her mother when the

patient got so upset the actions were irreversible for the remainder of that relationship.

Medication Reason side effects experiencing Side effects generalized

Depakote 500mg schizophrenia Dizziness, Sedation, Agitation, dizziness

Agitation ,headache, insomnia,
visual disturbances,
hepatotoxcity,
pancreatitis, abdominal
pain, anorexia,
diarrhea, indigestion,
nausea, vomiting,
tremor
Lexapro 20mg depression none Insomnia, diarrhea,
nausea
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Process Recording with Heartland Patient

Zyprexa 20mg schizoaffective Agitation, constipation, Agitation, dizziness,

headache, restlessness,
weight gain, sedation sedation, weakness,
orthostatic
hypotention,
amblyopia, constipation
dry mouth

Other medication Reason Interaction

Colace 100mg Constipation Not signifigant

Synthroid 100mg hypothyroidism No interactions

Oscal 500mg Osteoporosis No interactions

Vitamin D 1000 units Decreased vitamin D No interactions

*all drug information collected from Davis’s Drug Guide 11th edition

The here and now issues that were discussed was the issue at hand. There was not a visible

social issue at first but when there was a confrontation from the staff member there was a big issue.

That was the main topic of the conversation. The clients priority care needs from a nurse was to help

the patient calm down so the patient did not feel terrible about his or herself. Also it became clear that

another important thing was to make sure the patient was not in a state of mind that would escalate

into hurting the patient or someone else like she threatened earlier in a conversation with a nurse. “The

PERSONS acronym is one framework for identifying essential data to collect in the initial interview”.

(Morh). Although, the way that I did things was not as planed as this was. This PERSONS acronym is
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Process Recording with Heartland Patient

useful even after the interview to detect problems and put them in to an order based on severity. The

GAF sale was helpful in the charting because they have the axis ratings to what is most important as far

as diagnoses. Based on the client’s diagnoses the best intervention strategies would be to do some

crisis management (especially in the conversation that was shared) and also behavior modification.

These interventions are based on the patient’s bipolar diagnosis. The clients other main mental illness

diagnosis is schizophrenia which is in remission but his/her bipolar illness is what seems to be the main

problem for him or her.

The first issue I had was a legal issue. Because she was making threats it was my job to report

that she wanted to act out on her anger. Before I got to do that the staff came in and told me that is

what she was doing, so I knew that it was common knowledge that everyone knew what was going on. I

was able to agree that’s the tone she was taking even though the patient was getting better the more

we talked. The second issue was even harder for me to handle and that was the problem of advocacy

for the patient. It was hard for me to see the patient get talked down on especially since the patient

was not being malicious, or meant any harm to the diabetic patient. The staff member knows that the

patient is bipolar and a history of violence and anger issues and also the patient is diagnosed with mild

retardation. So, even thought the patient was told to through away her juice the patient may have not

comprehended the command or cannot see why a simple gesture like that could have negative effects

for oneself and potentially for the diabetic. The way that the staff talked to the patient would have

been rude for a person who did not have mental illness problems let alone someone with the problems

that the patient has to deal with. The staff member was not helping the patient with coping, or using

any therapeutic ways of correcting the patient. The staff was being down right offensive and was

actually potentially harming her fellow workers and the patients around my patient because of my

patient’s attitude toward anger and her past history of violence. This being said, I would have liked to

have done something about it because I felt the need to advocate for the patient but at the same time I
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Process Recording with Heartland Patient

am a nursing student and cannot confront the staff because I do not want the staff to be rude to the

students now or in the future. I felt at that moment I was stuck between a rock and a hard place

because I wanted to be an advocate but still be a good representative of the school. Also, it would have

been hard to voice my opinion because all the nurses heard the commotion and were on her side

because I could hear them in the nurses unit talking about my patient and making fun of her. It was

unprofessional and I will do my best to advocate my patient when we have to write a review for

Heartland. Also, I am sure that this will be an experience I will never forget and when I am a nurse I will

not be silent because my opinion will matter and I will make sure that people know that and my patients

will be better taken care of for that reason.

I feel that I am always improving and learning at every clinical. It seems like every day I

get something accomplished and a new skill is learned. This mental health rotation is already benefiting

my communication skills. Different situations especially in the units come up all the time and a nurse

has to be ready with a response right there and if the wrong thing is said then that could set a person

off. So, a nurse really needs to be skilled in the communication aspect and leaning about

communication this rotation had been interesting to say the least. This group of people in the clinical is

a good mix and I think that everyone is getting along well. I know there is not any person this far that I

have had an issue with and expect that to hold true for the rest of the rotation. Also, I feel that I am

open to speak my mind without being judged which is important in a group setting. The skills that are

becoming more comfortable to me are communication and being able to get the patient to feel

comfortable with me because I look relaxed. Also, I am improving my “poker face”. The nurse’s have

that down really well at Heartland and I think I am starting to get the hang of that. Other than

communication the mental status exam is a big part of the nurses’ job and I am improving on knowing

what to look for in a patient for the first time and how to answer the exam questions more accurately.

There are always going to be areas of improvement. I think that my biggest challenge this rotation is
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Process Recording with Heartland Patient

getting the medication down. There are a lot of medications and a lot for the same problems but that is

customary no matter where the rotation is. Learning the medication lists and knowing what they affect

and the side effects of a drug has always been big challenge for me but is something that I am constantly

working on. Another thing that I am in need of developing is more self confidence in what I know how

to do. This will make things easier for me eventually. The last skill I want to further develop is when

communicating with a client, be more comfortable in being therapeutic verses topical. It feels like

sometimes all I talk about it superficial things with the client which is not beneficial to either the client

or me. These are just some of the things I am constantly working on.
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Process Recording with Heartland Patient

References

Deglin, J. H., & Vallerand, A. H. (2010). Davis's Durg Guide for Nurses eleventh edition (11th

ed.). phikadelphia: F. A. Davis.

Psychiatric-mental Health Nursing Evidence-based Client Centered Care 7th Ed + Lippincott's

Video Guide to Psychiatric Mental Health Nursing Assessment. (2009). Philadelphia:

Lippincott Williams & Wilkins.